Endo Flashcards
(188 cards)
1
Q
in a pregnant lady under 25 with type 1 diabetes, what are the chances ( x in x) of her baby getting T1DM?
A
1 in 25
1
Q
what can trigger Waterhouse Friderichsen Syndrome
A
Neisseria meningitides or strep pneumo infection
2
Q
what pathological process that Waterhouse Friderichsen Syndrome lead to?
A
DIC
3
Q
sulfonylurea MoA
A
increase insulin secretions
4
Q
examples of sulfonylureas
A
glimepiride, gliclazide
5
Q
name a drug that reduces the absorption of levothyroxine
A
calcium carbonate
iron
6
Q
blood ketones in DKA
A
> 3 mmol/L
7
Q
bicarb in DKA
A
< 15
8
Q
Side effects of thyroxine over replacement [4]
A
hyperthyroidism
worsening angina
AF
osteoporosis
9
Q
3 keys features of primary hyperaldosteronism
A
hypokalaemia
hypertension
metabolic alkalosis
10
Q
if CT is normal, how can unilateral and bilateral causes of hyperaldosteronism be differentiated
A
adrenal venous sampling
11
Q
treatment of bilateral adrenal hyperplasia
A
spirinolactone
12
Q
what is the principle of management of Addisons disease?
A
steroid replacement with hydrocortisone and fludrocortisone
13
Q
what patient education must be provided for those with Addisons? [4]
A
- emphasise the importance of not missing glucocorticoid doses
- consider MedicAlert bracelets and steroid cards
- patients should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis
- discuss how to adjust the glucocorticoid dose during an intercurrent illness
14
Q
how should hydrocortisone and fludrocortisone dose change with intercurrent illness in Addisons?
A
double the hydrocortisone
keep fludrocortisone the same
15
Q
how is hydrocortisone replacement given in Addison’s disease?
number of doses in the day and time of day
A
2-3 doses a day, usually within the first half of the day
16
Q
which conditions can cause a lower than usual HbA1c reading [3]
A
G6PD deficiency
hereditary spherocytosis
haemodialysis
i.e. anything that reduced RBC survival
17
Q
which conditions can cause a higher than usual HbA1c reading [3]
A
splenectomy
IDA
vitamin B12/folate def
anything that make more RBCs, bigger RBCs or survive longer
18
Q
how can you differentiate HHS from DKA
A
- happens over a longer time frame
- no significant ketosis <3
- very high glucose >30
- no significant acidosis bicarb >15, pH >7.3
19
Q
key diagnostic features of HHS [4]
A
hypovolaemia
hyperglycaemia
raised serum osmolarity
no significant ketosis/acidosis
20
Q
treatment of HHS [3]
A
IV fluids
insulin
VTE prophylaxis
21
Q
complication of HHS
A
hyperviscosity leading to MI and stroke
22
Q
causes of hypernatraemia: increase in salt [3]
A
- high intake
- Conn’s/BAH
- Renal artery stenosis
both cause high aldosterone
23
Q
causes of hypernatraemia: loss of water [3]
A
- osmotic diuresis
- diabetes insipidus
- GI loss and sweat
24
4 causes of nephrogenic DI
hypercalcaemia
hypokalaemia
lithium
sickle cell anaemia
25
complication of rapid hypernatraemia correction
cerebral oedema
26
complication of rapid hyponatraemia correction
central pontine myelinolysis
27
hypervolaemic hyponatraemia: 3 causes and the mechanism causing hyponatraemia
cardiac failure
cirrhosis
renal failure
first two lead to excess water being held because of increased ADH due to low pressure states
renal failure is unable to get rid of water
28
euvolaemic hyponatraemia [4]
- psychogenic polydipsia
- hypothyroidism (low BP, ADH released)
- adrenal insufficiency (no Aldo)
- SIADH (water retention, suppress RAAS, less Aldo)
29
drugs that can cause SIADH [5]
SSRI
TCA
PPI
carbamazepine
sulphonylureas
30
2 drug treatments for SIADH
demeclocycline
tolvaptan
31
symptoms of central pontine myelinolysis [4]
quadriplegia,
dysarthria
seizure
coma and death
32
6 causes of hyperkalaemia
1.low GFR
2. high Renin (Type 4 RTA and NSAIDs)
3. ACE inhibitors
4. ARBs (Angiotensin 2 Receptor Blockers)
5. Addison’s disease
6. Aldosterone antagonists (i.e. spironolactone)
33
4 categories of causes of hyperkalaemia
- renal impairment
- drugs
- release from cells
- low aldosterone
34
features of hyperkalaemia on ECG [4]
- tall tented T waves
- PR prolongation
- broad QRS
- flat P wave
35
late ECG sign in hyperkalaemic indicating peri-arrest
sine wave
36
causes of hypokalaemia [5, non drug]
- GI losses
- Cushing's
- Conn's
- RTA (1 and 2)
- hypomagnesaemia
37
drugs that causes hypokalaemia
loop and thiazide diuretics
insulin
beta agonists
38
ECG features of hypokalaemia [3]
ST depression
flat T waves
U waves
39
when measuring aldosterone: renin ratio, what does a high aldosterone indicate?
what does a high renin indicate?
high aldosterone --> Conn's
high renin --> RAS
40
treatment of mild/mod hypokalameia
oral KCl e.g. SandoK
41
treatment of severe hypokalaemia [2]
IV KCl (3x 1L bag of saline with 40mmol KCl)
cardiac monitoring
42
ECG finding in hypocalcaemia
long QT
43
main electrolyte abnormality in refeeding syndrome
hypophosphataemia
44
signs of refeeding syndrome [4]
rhabdo
low resp rate
arrhythmia
shock and seizures
45
management of refeeding syndrome
phosphate supplementation
46
ECG sign in hypercalcaemia
short QT
47
1st line bloods in investigating polyuria
U&Es, glucose, paired serum & urine osmolarity, serum calcium
2nd line: water deprivation test
48
which arteries does fibromuscular dysplasia (FMD) affect predominantly
renal and cervical arteries
49
signs of renal artery FMD [3]
resistant hypertension
unilateral small kidneys
bruits
50
signs of cervical artery FMD [2]
chronic migraines
pulsatile tinnitus
51
gold standard investigation for FMD
CTA, catheter angiography
52
management of FMD [4]
1) stop smoking
2) clopidrogrel
3) ACEi or ARB
4) stenting of arteries
53
tongue sign of B12 def
glossitis
54
highly sensitive AB in Vitamin B12 def
anti parietal
55
highly specific AB in vitamin B12 def
anti Intrinsic factor
56
1st and 2nd line AB to check in vitamin B12 def
1st: anti IF
2nd: anti parietal cell (not used)
57
management of vit b12 def: what are the two preparations of B12 replacement
cyanocobalamin PO
hydroxycobalamin IM
58
2 metabolic disorders that cause hypomagnesaemia
Gitelman's and Barter's
59
two electrolyte abnormalities causing low Mg
hypokalaemia
hypocalcaemia
60
what drug toxicity can hypomagnesaemia exacerbate
digoxin
61
treatment of hypomagnesaemia
PO or IV MgSO4 depending on severity (<> 0.4 mmol/L)
62
when should an SGLT-2 inhibitor be added to meds for a diabetic
used in addition to metformin as initial therapy for T2DM if CVD, high-risk of CVD or chronic heart failure
63
how should Muslim diabetics take metformin during Ramadan?
dose should be split one-third before sunrise (Suhoor) and two-thirds after sunset (Iftar)
64
The standard HbA1c target in type 2 diabetes mellitus
48 mmol/mol
65
LH and testosterone levels in Klinefelter's?
High LH
Low testosterone
66
Radioiodine uptake in Grave's disease
diffuse homogenous uptake
67
Key investigation for Addison's
short synacthen test
68
Key investigation for Cushing's
overnight dexamethsone
69
high aldosterone:renin ration mean
Indicates aldosterone is being produced independently of renin, so the cause is primary (originating in the adrenals).
70
low aldosterone: renin ratio means
indicates aldosterone is raised due to renin being raised, so the cause is pathology of the renin-angiotensin-aldosterone axis e.g. renal artery stenosis
71
useful serology to diagnose T1DM
low C-peptide
72
how do you distinguish between type 1 and type 2 diabetes in the bloods
diabetes-specific autoantibodies:
- Antibodies to glutamic acid decarboxylase (anti-GAD)
- Islet cell antibodies
73
in what % of patients are eye signs seen in graves
30% therefore absence does not rule it out
74
Characteristic histology in papillary thyroid cancer
Orphan Annie eyes
75
tumour marker for papillary and follicular thyroid cancer
thyroglobulin
76
drug treatment for prolactinoma [2]
cabergoline, bromocriptine
77
triad seen in phaeochromocytoma
sweating
headaches
palpitations
in association with severe headache
78
management of phaechromocytoma before definitive surgery
alpha blockade e.g. phenoxybenzamine followed by beta blockade e.g. propranolol
79
what must be done with an incidentaloma found in the pituitary sella
which scan is best
all patients with a pituitary incidentaloma, including those without symptoms, undergo clinical and laboratory evaluations for hormone hypersecretion and hypopituitarism.
MRI
80
Most common pituitary adenoma
prolactinoma
After prolactinomas, non-secreting adenomas are the next most common, then GH-secreting and then ACTH-secreting adenomas.
81
How do non-functional pituitary adenomas present
depletion of a hormone(s) (due to compression of the normal functioning pituitary gland) therefore, present with generalised hypopituitarism
82
treatment of GH-secreting adenomas
somatostatin analogues (e.g., octreotide, lanreotide) and GH receptor antagonists (e.g., pegvisomant)
83
First line treatment for most patients with a pituitary tumour causing acromegaly
trans-sphenoidal surgery
84
two common side effects of sulfonylureas
weight gain
hypos
85
what hypoaldosteronism condition is caused by meningococcal septicaemia
Waterhouse-Friedrichsen syndrome
86
drugs that can raise prolactin [4]
metoclopramide, domperidone
phenothiazines
haloperidol
very rare: SSRIs, opioids
87
TFTs in sick euthyroid syndrome
low T3/T4 and normal TSH with acute illness
88
when is insulin started in HHS
if the glucose stops falling while giving IV fluids
89
what key thing must also be given in HHS treatment alongside fluids and insulin
thromboprophylaxis due to hyperviscosity
90
cardiac complication of acromegaly
cardiomyopathy
91
6% of acromegaly patients have _____
MEN-1
92
causes of hypogonadotrophic hypogonadism
haemochromatosis
Kallman's
93
management of gastroparesis in diabetes
pro kinetics e.g. metoclopramide, domiperidone
94
treatment of neuropathic pain in diabetes
amitriptyline, duloxetine
95
waking target in T1DM
5-7 mmol/L
96
how often should BM monitoring be done during illness
every 4 hours
97
what is the alternative to basal-bolus regimen
pre-mixed regimen given at the start of breakfast and dinner
98
pre-diabetes HbA1c threshold
how is this managed
42-48
diabetes prevention programme
99
what drugs are given to address cardiovascular risk factors in DM
aspirin
ACEI/ARB
statin
100
MoA of metformin
increase insulin sensitive and decrease hepatic gluconeogenesis
101
contraindications of metformin [4]
eGFR <30
tissue hypoxia e..g MI, surgery
iodine contrast
alcohol abuse
102
when does diabetic therapy become dual therapy
when HbA1c rises to >58 /7.5%
103
when starting dual therapy for DM, what does the HbA1c target become
< 53 mmol/L or 7%
104
which cancer is a contraindication to pioglitazone
bladder cancer
105
treatment of MODY
sulfonylurea
106
treatment of late onset DM (LADA)
hypoglycaemics followed by insulin
107
investigation for MODY and LADA
MODY: C peptides
LADA: GAD antibodies and low C-peptide
108
rate of insulin infusion on DKA
0.1U/kg/hr
109
Treatment algo for DKA [5]
fluids
insulin with 10% detrose
potassium replacement
VTE prophylaxis
110
insulin infusion rate in HHS
when is it started?
0.05U/kg/hr sliding scale once BM stop dropping or ketones start rising
111
TSH and T4 in thyrotoxicosis
TSH LOW
T4 HIGH
112
TSH and T4 in primary hypothyroid
TSH HIGH
T4 LOW
113
TSH and T4 in secondary hypothyroid
TSH LOW
T4 LOW
114
TSH and T4 in sick euthyroid syndrome
TSH LOW/NORMAL
T4 LOW
T3 very low
115
TSH and T4 in subclinical hypothyroid
TSH HIGH
T4 NORMAL
116
TSH and T4 in poor thyroxine compliance
TSH HIGH
T4 NORMAL
117
TSH and T4 in steroid therapy
TSH LOW
T4 NORMAL
118
when should USS and FNA of a thyroid lump be done
> 1cm
119
management of thyroid cancer
Hemi thyroidectomy + iodine 131 too kill remaining cells
follow up: measure TG or calcitonin, I-123 body scans
120
Causes of hyperthyroid that cause low uptake [2]
Sub acute thyroiditis/Viral thyroiditis/de Quervains
post partum thyroiditis
121
features of thyroid acropachy [3]
digital clubbing
soft tissue swelling
periostea new bone formation
122
best preventative measure of Grave's
stop smoking
123
treatment of Graves in primary care
propanolol
124
1st line anti thyroid
carbimazole
125
2nd line antithyroid
PTU
126
what is used to treat Graves if antithyroid medication don't work
what are the side effects
radioiodine
SE: hypothyroid, thyroid storm
127
treatment of thyroid storm
Propanolol IV
PTU
Prednisolone/Hydrocortisone
POtassium iodide
128
investigation of Hashimoto's thyroiditis
anti TPO abs
129
most common cause of hypothyroidism in the UK and the developing world
UK: hashimotos
developing world: iodine deficiency
130
when should sub-clinical hypothyroidism be treate; with what?
when TSH >10 with levothyroxine
otherwise just observe
131
treatment of myxoedema coma [3]
thyroxine IV
hydrocortisone IV
fluids IV
132
1st line investigation in Addison's
(9 am) plasma cortisol
if <500 --> short synacthen then measure cortisol after 30 minutes, cortisol will still be <500
133
signs and symptoms of pituitary adenoma [4]
- excess hormones (acromegaly, Cushing's, amenorrhoea)
- hormone depletion
- bitemporal hemianopia
- headaches
134
investigations for prolactinoma [3]
bloods for pituitary hormones
visual field testing
MRI brain with contrast
135
investigation for acromegaly [2]
1st Serum IGF-1
if raised --> OGTT with serial GH measurements to confirm diagnosis
MRI brain with contrast
136
2nd line treatment of acromegaly
somatostatin analogue e.g. octreotide
137
Causes of Cushing's syndrome can be split into exogenous and endogenous. Endogenous causes are further split into ACTH dependent and ACTH independent
what are the dependent causes [2]
Cushing's disease (adenoma)
Ectopic ACTH production
138
Causes of Cushing's syndrome can be split into exogenous and endogenous. Endogenous causes are further split into ACTH dependent and ACTH independent
what are the INdependent causes [4]
iatrogenic steroids
adrenal adenoma
adrenal carcinoma
Carney complex
139
what are the causes of pseudo Cushings [2]
how can you differentiate it from true Cushing's
alcohol XS or severe depression
causes a false positive dexamethasone suppression test
differentiate with insulin stress test
140
1st line investigation of Cushings [2]
salivary cortisol
low dose dex suppression test [fails to suppress]
141
how is a low dose dex suppression test carried out
dose taken before bed at 11pm (1mg) and cortisol is measured at 9 am the next day
in Cushing's, the cortisol will still be high
142
how do you distinguish pituitary dependent Cushing's to ectopic ACTH Cushing's
Inferior Petrosal Sinus Sampling
catheter fed into the jugular vein
143
management of Cushing's
- pituitary adenoma
- adrenal adenoma [2]
- ectopic [3]
- pituitary adenoma --> surgery
- adrenal mass --> adrenalectomy + steroid replacement
- ectopic --> ketoconazole, metryapone, mifepristone
144
3 investigations in Conn's
plasma aldosterone:renin ratio
HR-CT
adrenal venous sampling (uni vs bi)
145
cause of high aldosterone: renin ratio and normal ratio
high in Conn's and normal in renal artery stenosis
both end with high aldosterone.
in RAS the high renin leads to aldosterone production
146
management of Conns
solitary adenoma--> spironolactone/epleronone + surgery
bilateral or elderly --> spironolactone/epleronone
147
how does hypocalcaemia present [2]
pareasthesia in fingers toes and periorally
muscle cramps and spasms
148
calcium level in secondary hyperparathyroidism
LOW
149
definitive treatment of hyperparathyroidism
total parathyroidectomy
cinacalcet if non surgical candidate
150
which forms of multiple myeloma have no CRAB features or Signs & Symptoms
MGUS and smouldering myeloma
151
difference between MGUS and smouldering myeloma [3]
monoclonal serum protein; BM plasma cell levels and risk of progression
< 30g/L serum protein and <10% plasma cells in MGUS
low risk of progression to MM
>30g/L serum protein and >10% plasma cells in SM
10% risk of progression to MM
152
which Ig protein in found in Walderstroms
IgM
153
investigation to do in subclinical hypothyroidism
check for thyroid peroxidase antibodies
154
what should be done for those with TSH is between 5.5 - 10mU/L and the free thyroxine level is within the normal range and asymptomatci
observe and do TFT in 6 months
155
what should be done for those with TSH is between 5.5 - 10mU/L and the free thyroxine level is within the normal range and are < 65 years consider
offering a 6-month trial of levothyroxine if:
the TSH level is 5.5 - 10mU/L on 2 separate occasions 3 months apart,and
there are symptoms of hypothyroidism
156
If a triple combination of drugs has failed to reduce HbA1c, what is done
switching one of the drugs for a GLP-1 mimetic is recommended, particularly if the BMI > 35
157
complications of thyroid eye disease
**Exposure keratopathy**
this is the **most common complication** of thyroid eye disease
due to eyelid retraction and proptosis (exophthalmos) → cornea becomes excessively exposed, disrupting the normal tear film → dryness, irritation, and corneal ulceration
symptoms include foreign body sensation, pain, and photophobia
in severe cases, it can lead to corneal scarring and vision impairment.
**Optic neuropathy**
one of the **most serious complications** of thyroid eye disease
occurs when enlarged extraocular muscles compress the optic nerve at the apex of the orbit → a reduction in visual acuity, colour vision deficits, and visual field defect
it requires urgent medical intervention to prevent permanent vision loss.
**Strabismus and diplopia**
fibrosis and enlargement of the extraocular muscles can result in restrictive strabismus → misalignment of the eyes → double vision (diplopia)
this not only affects visual function but can also significantly impair the quality of life.
158
adverse effects of gliflozins [3]
urinary and genital infection (secondary to glycosuria). Fournier’s gangrene has also been reported
normoglycaemic ketoacidosis
increased risk of lower-limb amputation: feet should be closely monitored
159
how often should you monitor BMs
at least 5 times a day for children and young people
at leas 4 a day for adults
before meals and before bed
160
1st line insulin regime in newly diagnosed type 1 diabetics
basal–bolus using twice‑daily insulin detemir
161
when should metformin be added to the management of type 1 diabetes
when BMI >= 25
162
beneficial side effect of SGLT-2 inhibitors
weight loss
163
how does pioglitazone cause weight gain
fat and fluid retention
164
features of Kallmans [6]
'delayed puberty'
hypogonadism, cryptorchidism
anosmia
sex hormone levels are low
LH, FSH levels are inappropriately low/normal
patients are typically of normal or above-average height
165
LH and FSH levels in Kallmans
low to normal
166
treatment of Kallmans [2]
testosterone supplementation
gonadotrophin supplementation may result in sperm production if fertility is desired later in life
167
thyroxine requirements in pregnancy
women require an increased dose of thyroxine during pregnancy
by up to 50% as early as 4-6 weeks of pregnancy
168
'unrecordable' blood glucose always means
BMs are very high
169
criteria for DKA resolution [3]
pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L
170
what should be done if ketonaemia and acidosis have NOT resolved within 24 hours
call senior
171
when can IV insulin be changed to SC insulin in DKA management [2]
ketonaemia and acidosis have resolved according to criteria
and
pt is eating and drinking
patient should be reviewed by the diabetes specialist nurse prior to discharge
172
complication associated with DKA management
cerebral oedema
173
DVLA count a 'severe' episode as one in which.... (hypos)
help is required
174
what effect does magnesium have on calcium
Magnesium is required for both PTH secretion and its action on target tissues. Hypomagnesaemia may both cause hypocalcaemia and render patients unresponsive to treatment with calcium and vitamin D supplementation.
175
genotypically male children (46XY) to have a female phenotype. Rudimentary vagina and testes present but no uterus.
androgen insensitivity syndrome [x-linked]
elevated testo, LH and oestrogen
176
inability of males to convert testosterone to dihydrotestosterone (DHT). Individuals have ambiguous genitalia in the newborn period.
5-α reductase deficiency[AR]
Hypospadias is common. Virilization at puberty.
177
investigation of neuroblastoma
raised urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels
calcification may be seen on abdominal x-ray
biopsy
178
where do neuroblastoma arise from
neural crest tissue of the adrenal medulla (the most common site) and sympathetic nervous system.
179
Consider further investigation in adults that involves measurement of C‑peptide and/or diabetes‑specific autoantibody titres if:
type 1 diabetes is suspected but the clinical presentation includes some atypical features (for example, age 50 years or above, BMI of 25 kg/m² or above, slow evolution of hyperglycaemia or long prodrome)
180
Minimal glucocorticoid activity, very high mineralocorticoid activity,
Fludrocortisone
181
Glucocorticoid activity, high mineralocorticoid activity,
Hydrocortisone
182
Predominant glucocorticoid activity, low mineralocorticoid activity
Prednisolone
183
Very high glucocorticoid activity, minimal mineralocorticoid activity
Dexamethasone
Betmethasone
184
alcoholic ketoacidosis vs diabetic ketoacidosis
alcoholic ketoacidosis has normal glucose levels unlike DKA
185
which drug needs to be stopped before CT with contrast
metformin
can worsen contrast induced nephropathy
186
management of diabetic neuropathic pain if GFR <30
amitriptyline
duloxetine can't be used if GFR <30
187
what would bony mets do to PTH
suppress it
in primary hyperPTH, PTH can be normal
